Soccer and Vocational Training are Ineffective Delivery Strategies to Prevent HIV and Substance Abuse by Young, South African Men: A Cluster Randomized Controlled Trial

HIV incidence is about 2.4% annually among men aged 18–29 years in sub-Saharan Africa [1], including South Africa [2]. This results in an HIV prevalence rate of about 17% among young men [3]. Yet, HIV is only one of a cluster of challenges young men face when reaching adulthood. Rates of alcohol and drug use are syndemic with HIV among young men [4‐7]. About half (56%) of young, South African men have engaged in binge drinking at least once in the past 3 months [8]. Under the influence of substances, sexual behaviors are disinhibited, increasing HIV risk for young men [9]. Concurrently, violence is often precipitated by substance abuse, including violence in the context of gangs and with intimate partners [4, 10]. In this study, about one third had been previously arrested and often had mental health symptoms [11]. This study aims to reduce this cluster of risk behaviors found among young men 18–29 years old.

Currently, there is a mismatch between where and how preventive and treatment services are offered and young men's uptake of these services. Almost all HIV interventions are embedded in health clinics [12, 13], a setting underutilized by men [14]. Men underutilize not only primary health care and HIV testing services, but are less likely to adhere to prevent and treat regimens if living with HIV [15‐17]. Even when men engage in health care, the experience is often off-putting to men. HIV interventions are typically designed as individual counseling delivered by young women [18], and the topics are focused on seeking care and sharing experiences [19, 20]. Seeking help is often perceived as inconsistent with male identity [21].

We identified two attractive intervention settings to deliver evidence-based, cognitive-behavioral interventions to address young men's risk acts: soccer leagues and vocational training centers. Sports are highly attractive recreational activities that almost all men enjoy [22, 23]. Sports also form a central aspect of South Africa’s identity [24]. In the context of playing soccer, young men have an opportunity to acquire healthy habits of daily living and to build positive community norms (e.g. showing up on time for soccer with no drugs/alcohol, supporting teammates to refrain from violence). Engaging in sports has also been associated with reduced rates of substance abuse and HIV risk [25‐27].

Yet, when previous sports interventions have been evaluated, researchers have typically found potential benefits limited to increased knowledge regarding HIV prevention and more positive attitudes towards prevention [28]. In a pilot study delivering HIV interventions during soccer to young men, more than 80% of young men regularly attended practices/games over 6 months and reduced their substance abuse [21]. Even if they were not good players, the young men valued being part of the team [21]. Families reported that soccer occupied the young men daily, gave them respect in the community, and the Saturday games were an opportunity for the community to attend and value the young men [29]. With all men meeting together at soccer, a traditional cognitive-behavioral, HIV and substance abuse intervention program could be implemented during a half time break. It was a novel intervention delivery method that structurally addressed all young men in a neighborhood at the same time, with the hope of shifting the social determinants of HIV for an entire community. With community members sharing the intervention experience and building new norms, the power of a traditional cognitive-behavioral program.

The second structural intervention was to offer young men vocational training. In Cape Town, 57.4% of young people are unemployed [30] and it is estimated that COVID-19 has led to another 2 million unemployed young people [30]. Going to work reduces opportunities for being part of gang activities and using drugs and alcohol, in addition to providing income that improves the quality of life. The South African government has established the Services Sector Education and Training Authority (SSETA), a jobs training program operated by the Department of Labor [31]. Though there is an annual budget of more than R3 billion, fewer than 0.9% of people receiving SSETA’s vocational training are provided with any type of on-the-job training and 60% are unemployed at the program’s completion [32]. Men have often been excluded from traditional economic development programs such as cash transfers and microfinance [33, 34]. For example, the success of the Grameen Bank in Bangladesh focused the world’s attention on microfinance as a strategy for poverty alleviation, but men are excluded [35, 36]. The few times men have been studied, the programs have been highly successful [37, 38]. Yet, policies have not changed to include men in programs involving cash transfers [39].

To reduce risk behaviors over the long term, young men need pathways out of poverty, as well as the behavioral skills to protect themselves from HIV and substance abuse problems. We offered young men immediate access to vocational training, with free transportation and tools to sustain their work at graduation from vocational training—potentially a pathway out of poverty.

To test the efficacy of these structural, community-level interventions, a three-arm, clustered randomized controlled superiority trial was designed with 27 matched neighborhood areas. For every three matched areas, UCLA randomized one area to: (1) receive soccer for 12 months (SL); (2) receive soccer for six months and vocational training for the next six months (SL/VT); or (3) to be control communities (CC). We hypothesized that the young men in the CC would engage in more sexual and substance abuse risk behaviors, fewer HIV protective behaviors, and be employed less often than men in the two intervention conditions. It is not clear whether 12 month involvement in soccer and prosocial community contact would have better outcomes (less risk and more protective behaviors) than a combination of soccer/vocational training. We wanted to evaluate which intervention strategy was optimal for young men.

Regardless of intervention condition, men continued to report substantial rates of substance abuse and risk for HIV 18 months after initiating the intervention. There were no consistent significant differences in any of the domains targeted in the intervention: sexual risk acts, substance abuse, violence, community involvement, and employment. This is disappointing in a year in which South Africa has the highest rate of HIV and a 33% increase in unemployment [30]. There are, however, a series of challenges and observations provided by these negative results.

First, even structural interventions may not succeed if interventions are not ongoing, comprehensive and possibly directly address hopelessness. We offered this intervention to all men within a community, in order to maximize the potential impact of peer support and comraderie for the acquisition of new behaviors. In particular, substance abuse programs are often designed so that young people are sent to treatment facilitates and then return to their existing networks, with high rates of substance abusers. This project was designed to shift the norms and behaviors within a community.

We did observe both relatively high uptake of the soccer intervention, and uptake increased over time. On weekly random drug tests given on the soccer field, we initially observed reductions in use. Yet, there are many holiday breaks in South Africa. In particular, at Christmas there is often a break of up to six weeks. Many young persons travel home to the Eastern Cape. During these periods, whatever substance use had decreased, returned and increased. Holidays in the entire society have alcohol as part of its celebration. This study was conducted in the Western Cape of South Africa, an area where for many generations, Black families worked on the wine farm and were paid at least partially with alcohol each week. During training, one of the first supervisors provided by a local non-profit shared his own philosophy, which did not appear atypical—I have a paying job and I am entitled to spend my income on alcohol. When questioned, he believed a case of hard liquor a month was reasonable. There is no way to know if this young supervisor was typical of his peers. Over 18 months there are two Christmas seasons, Easter break, and a summer vacation. We previously reported that these breaks in soccer play were characterized by patterns of significant and increasing substance abuse throughout the broader society [50]. Alcohol use is ubiquitous in some communities, and alcohol consumption forms the basis of significant amounts of peer interaction. In this context, substance use may be difficult to overcome, even when the community's family is supportive [51].

Second, more than half of the young men in the neighborhoods randomized to the vocational training intervention never registered for the training and even fewer graduated. Free transportation, food, and a promise of free tools at the end of training were unconvincing suggesting that for many men they saw little way out of unemployment. There can be many reasons for this failure to take up the programs.

A program with very similar goals to this project was mounted by this team in Uganda [52]. In Uganda, it was very easy to identify vocational training programs that offered apprenticeships. We were able to quickly identify local, one-man shops who were eager to have an apprentice—car repair, mobile phone repair, painters, construction work. In addition, there were large vocational training operations that had stable funding, in which apprenticeships were common. There was the hope that, if the trainee performed well, the trainee could join the trainer in their work. There was no such system or organization in South Africa. When we found such an organization, they were bankrupt soon. Despite South African government funding, there are few apprenticeships, and large amounts of unspent SSETA funds annually. In preparing to launch this vocational training program, we collaborated with more than six organizations. Almost all had gone out of business before we could implement the study. Each of these organizations pointed to the cumbersome government paper-work required to access SETA funds, as well as challenges enrolling and keeping young people in their programs. Even in the successful vocational training programs, we found many challenges. Our qualitative data suggest the young men found classroom-based training to be highly aversive. Yet, this was the prototypical training mode. Young men’s disinterest in vocational training may reflect their realistic appraisal that the training would not lead to a job. The models for vocational training were quite different in South Africa and lifetime unemployment rates are high. We could only offer four choices for vocational training and each started in a classroom, not on a job site. This appears unattractive to young men.

Third, ongoing stressors of young men's lives may inhibit consistency of behaviors over time. Young men often reported that they went to the Eastern Cape to "hide-out" because a negative community or interpersonal challenge occurred, and they wanted to avoid police or gangs. Those who went to the Eastern Cape were more likely to be those with fewer risk behaviors. There were also 13 deaths over the course of the study (12 of 778 in interventions; 1 of 415 in the CC). This is substantial over 18 months; we expect that the rate is even higher, but we had fewer tracking resources for young men in the CC condition. While this difference was not significant, it is possible that assembling men in groups can facilitate problem behaviors, as has previously been described by Dishion and colleagues [53].

These data highlight the importance of identifying a new approach to creating a pathway to health and employment for young men. Over time, multiple projects have failed to show soccer impacting the behaviors of either women [54, 55] or men [28, 55‐60]. Sport has been used effectively to encourage HIV testing on a single event of play [61], but sport only increased knowledge and improved attitudes towards prevention when attempting to increase male circumcision [62]. Either recreational activities are not a viable intervention delivery format or projects have failed to implement effective procedures. Yet, donor agencies have significantly invested in this approach. Donors may need to routinely monitor outcomes to warrant the investments in efficacious interventions.

In contrast to the results with soccer, vocational training has been demonstrated to be successful in other LMIC [63], including LMIC in Africa [63, 64]. Yet, there are substantial data indicating that young, South African men do not reap such benefits. Substantially different vocational training approaches are likely needed.

We hypothesize that both soccer and vocational training must be initiated far earlier, before the start of high school. It may be too late in early adulthood to entice men to return to school. Many had dropped out of traditional school by 10th grade. It had been a long time since their last class. Making job skills an integral part of high school and making high school a place where recreational activities such as soccer routinely occur may be a far better option than trying to create such activities in adulthood or expecting them to change behaviors. In addition, a national commitment to creating apprenticeship vocational training programs is likely a far more attractive intervention model than those currently being offered.